Date Approved


Graduate Degree Type


Degree Name

Nursing (D.N.P.)

Degree Program

Allied Health Sciences

First Advisor

Dr. Della Hughes-Carter

Second Advisor

Dr. Diane Slager

Academic Year




Background: Social determinants of health (SDOH) are associated with an increased risk of poor health outcomes and increased healthcare utilization (Buitron de la Vega et al, 2019). To achieve health equity, social determinants of health are an essential factor to assess. Practitioners (in the evaluated primary care setting) can document, track, update, and report SDOH through the electronic medical record (EMR). Yet, the electronic health record is not consistently being utilized for this purpose.

Objectives: This article describes a new protocol which was implemented, utilizing a module embedded in the EMR, to chart the results of a standardized SDOH screening tool on all wellness examinations and provide coordinating resource referrals for identified needs.

Methods: The project was implemented using the Sociotechnical Theory at a rural primary care practice in a Midwestern state. Participants included office staff and 91 patients. The QI project measures included: the results of a staff engagement survey pre/post implementation, the percentage of SDOH screenings documented at annual wellness examinations pre/post implementation, and the percentage of annual wellness examinations with a positive SDOH screening result that received a referral for a coordinating intervention through the EMR pre/post implementation.

Results: After implementing a SDOH Screening and Intervening Protocol, results indicated a percent increase of 4.4% of SDOH screening rates and a percent increase of 179.7% in resource referrals.

Conclusions: The SDOH Screening and Intervening Protocol showed a percent increase in both SDOH screening rates and resource referral rates in the EMR.

Implications: Addressing social needs through resource referrals has been shown to positively affect health outcomes and reduce healthcare spending (Yan et al., 2022).

Keywords: Social determinants of health, quality improvement, health disparities, social need referrals

Available for download on Monday, April 27, 2026